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pyo",cc STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 4'g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ° COMPLETE THIS FORM FOR EACH FACILrrY/SITE In MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION O T PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT E::] a AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR t G Ilk AODPrE9SNEAR9ST CR SS STREET PARCEL B(OPTI L) A-1,11) f-A" CITY NA — l STATE ZIP CODE S TE PHONE M WITH AREA CODE ✓ BOX 0 CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY a COUNTY-AGENCY' O S TE-AGEN Y' FEDERAL-AGENCY' TO INDICATE DISTRICTS 'downeroi UST' BpLtdoagercy,=PleteMefoWwng n cfswery rofd" ,mionorolfimwhi opertleslhe UST TYPE OF BUSINESS ❑ t GAS STATION 2 DISTRIBUTOR ❑ ✓IF INDIAN NOF TANKS AT SITE E.P.A. L D.k(opfbm1) 3 FARM N PROCESSOR 5 OTHER RESERVATION ^ ❑ ❑ OR TRUST LANDS dJ.� EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE N WITH AREACODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGH : N (LAST,FIR H W AREA PCODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ 0oe1ondrale Q INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY (]CORPORATION O PARTNERSHIP COUNTY-AGENCY 0 FEDERAL.AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxWndirele Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY =CORPORATION O PARTNERSHIP []COUNTY-AGENCY FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 14K- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓boao,,"te 0 1 SELF-INSURED O 2 GUARANTEE = 3 INSURANCE O I SURETY BOND ED s LETTEROFcREDTr O 6 EXEMPTION O T STATEFUND OBSTATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT 1310 LOCAL GOVT.MECHANISM ED 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY R,L J ' --A3 7 CO�UNTTY�N JURISDICTION N FACILITY a LOCATION CODE -OPTIONAL CENSUS TRACT N •OP ONAL •OP SUPVISOR-DISTRICT CODE TIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM -H THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI STORAGE TANK REGULATIONS FORMA(6-95)